Initiative helps keep uninsured out of ED

CMs help patients connect with PCPs

Case managers at the University of Michigan Faculty Group Practice help low-income individuals enrolled in a county-supported health plan learn to navigate the health care system and access primary care services so they can stay out of the hospital and the emergency department.

"Many of these patients have never received health care except by going to the emergency department. Many of them don't know how to make an appointment with the doctor for well care or when they are sick. We work on getting continuity of care for these patients. A big portion of our efforts is to educate them to access care appropriately," says Donna Fox, RN, health services manager and case manager for University Health System.

The practice, part of the University of Michigan medical school, includes all 1,500 faculty physicians who care for patients at three hospitals and 40 health centers operated by the University of Michigan.

The case managers manage individuals who are enrolled in the Washtenaw Health Plan, a partnership between Washtenaw County, the University of Michigan Health System, and St. Joseph's Medical Center, to provide medical coverage for low-income individuals who do not qualify for other public assistance health care programs.

More than 7,800 county residents are enrolled in the Washtenaw Health Plan, and about half of them receive their health care through the University of Michigan Health System. The two hospital systems absorb most of the cost for the care provided.

The program allows the uninsured to access health care appropriately, to make an appointment with the primary care provider, and to get referrals to specialists for medically required treatment, Fox says.

The case managers receive daily reports of patients covered by the plan who are admitted to the hospital or who have had an emergency department visit.

"We contact the patient to make sure they have gotten their medication, that they have a follow-up appointment with a primary care provider, and that they understand how to use the health system appropriately," she says.

The case managers explain the treatment plan and help the patients follow up so they won't have to go back to the hospital or have an emergency visit.

"Many of our patients simply do not understand how to manage their health care. They are confused by the system and don't know what to do," she says.

A lot of people sign up for the health plan while they are healthy but they don't see a doctor to establish a relationship before they get sick, Fox points out.

Then, when they are sick and can't get in to see a doctor for several weeks, they end up back in the emergency department.

"We help them understand that if they are a new patient, it will take a while for them to get in so they should have a physical and get established with a primary care provider before they are sick. We help teach them that they should see a physician, not go to the emergency room, when they are sick and help them recognize the symptoms that indicate they should call for an appointment," she says.

The case managers are notified when a patient in the program is hospitalized or makes a visit to the emergency department or if they call the health plan with questions, if they can't get an appointment with a doctor, or if they feel their doctor isn't listening to them.

Physicians also call the case managers to help when patients don't appear to understand the treatment plan.

"Sometimes it's a matter of low literacy or they are just so overwhelmed by their illness and their psycho-social issues that they don't understand what the doctor says. They get home and they don't understand what to do so they can call me for help," she says.

The case manager may attend appointments with patients to help them understand what the doctors are saying. They talk to the patient between visits to answer any questions and to make sure the patient is following the treatment plans.

If patients are referred to a specialist, the case managers follow up to ensure that the patients keep the appointments.

If the patients have problems paying for their medication or if it's not in the formulary, the case managers ask the physicians if there is a medication in the formulary that could be substituted. If that's not possible, the case managers help patients apply for a patient assistance program to cover the medication.

"We do whatever it takes to see that patients have continuity in care and that they get the assistance they need," she says.

For instance, they work with the state Medicaid agency to identify community resources, such as housing assistance programs, that can help the patients.

The case managers at both hospitals, representatives of the health plan, and county agencies meet regularly to talk about the program and how it might be improved.

"We brainstorm on some cases and help each other identify resources that might help our patients. We try to keep in tune with what is going on in the community so we can assist the patients in receiving the help they need," she says.

Most of the patients are enrolled in the health plan at the county health department offices. They choose their provider based on proximity.

The health plan covers the working poor who have some income and may have children. Indigent people who otherwise qualify for Medicaid but don't have a health condition also also enroll.

The program has a limited formulary for medications that includes basic types of antibiotics, statins, and blood pressure medications.

"They picked those that are most prescribed and most cost-effective. These aren't the newest and most expensive medications, but ones that are reliable and frequently used," Fox says.

The co-pay is minimal — $3 for most medications.